After shoulder surgery, intense rehab restores full function

On a Saturday in mid-August, while lifting a heavy box into his car, Joe Fudge heard a rip and his right arm went limp. By the Monday he had some motion back and the Daily Press photographer delayed for two weeks before seeking medical care. His primary care doctor then diagnosed a rotator cuff tear and sent him to a specialist.

The likelihood of such an injury increases proportionately with age. It can be exacerbated by shoulder overuse in sports — such as by pitchers and swimmers — but it can also occur with trauma. Most often, though, the tendon tear happens in the least dramatic way; for example, when someone's reaching into the back seat of the car to retrieve a book or other object, says orthopedic surgeon Jon Swenson.

To find out what's involved with the common, but torturous, procedure, we followed Fudge's journey from injury through surgery and rehab.

Less than three months after surgery, Fudge, 59, returned to work on Dec. 6, where he routinely carries between 15 and 20 pounds of photographic equipment at any one time. That puts his recovery on the rapid side of the typical range of three to six months. "I'm a very impatient person," he acknowledges, and was constantly pressing the doctor and therapists for how he could shorten the recovery timeline.

Diagnosis and surgery

After seeing his primary care doctor, Fudge had to wait two weeks for an MRI which confirmed the diagnosis. (X-rays cannot pick up a tendon tear.) He then sought out Swenson of Hampton Roads Orthopaedics & Sports Medicine, who had operated on a benign tumor on his foot in 2005. The arthroscopic surgery was scheduled for the earliest date he could get — three weeks away. Swenson made four or five incisions — "it looks like a shotgun blast," says the surgeon, examining his handiwork a few weeks later — during which the surgeon discovered that the damage was worse than initially believed.

In addition to the full tear of the tendon, the surrounding bones showed arthritis. "It wasn't a small repair. I put in a couple of anchors with sutures and took away the outer clavicle (removing 8mm bone with a motorized shaver). … The bone actually grows into the tendon. It heals slowly; that's why it just has to sit there," says Swenson, adding that, as a result, it would be more painful and sore than the average. He also trimmed the undersurface of the acromion bone to relieve pressure on the rotator cuff.

First check-up

At his three-week check-up in October, his arm in a sling, Fudge is on schedule, but impatient and frustrated with his progress. "You can't pick it up to scratch your nose," he says. He also cites the extreme pain that he endured the first night after the outpatient surgery, which caught him unprepared. Even going well over the prescribed amount of pain meds, Fudge describes the sensation as unbearable —"I woke up and thought someone was stabbing me." He continued to use painkillers for two weeks.

"The first two weeks were horrible. I feel like I'm human again," he says. However, he's still not using his right arm at all, other than to feed himself with a spoon. "A knife requires uncomfortable downward pressure," he explains. He's learned to comb his hair, shave and turn the car key, all left-handed. He's attending physical therapy, but all the exercises are passive, such as swinging the affected arm like a pendulum.

"You have to use common sense," urges Swenson. "The biggest danger is to re-tear the tendon; it continues to strengthen for at least six months and maybe a year. Don't push it, baby it." He advises Fudge that it will take seven to eight weeks before he can do anything really active.

Physical therapy

In late November, certified hand therapist Marcia L. Miller watches Fudge's eyes to determine when she's pushed him to the brink in the range-of-motion exercises. "The eyes will tell you first," she says, as she watches for wrinkles to appear in the corners. She starts the session by applying heat for 15 to 20 minutes to help the muscles stretch. After weeks in a sling, they're stiff. "The worst thing that can happen is for the shoulder to freeze in place," says Fudge. "You don't want to damage any of the repair work, but you don't want it to be stuck."

Ending his fifth week of therapy, he is making the transition from passive exercises to active in his thrice-weekly physiotherapy sessions. "You usually gain about 10 degrees a week on this motion," Miller says, using Fudge's elbow to crank the shoulder. She measures the angle — 65 degrees — with a goniometer. Fudge notes that he can now put his wallet in his back pocket and turn the car radio on and off, both day-to-day procedures that he couldn't perform two weeks before. "You have to think about things and plan them," he says. "The worst thing is putting on socks."

Fudge then goes through a circuit of other exercises, each timed and measured by assistant therapists. Just raising his arm unassisted shows progress. He still can't lift anything more than 10 pounds and a new exercise, using a "bodyblade," reminds him that his shoulder is still a work in progress.

Fudge describes the second and third weeks as the most discouraging mentally. "That's when they hurt you the most, when you start therapy. And, that's when you realize it's going to be a long process and you still can't do anything," he says.

Now he's back to work — but with therapy for another two months.

Rotator cuff tear

The rotator cuff is the group of four tendons and muscles that surround the shoulder joint. When injured, the most common symptom is pain or weakness of the shoulder that causes difficulty in lifting the arm overhead, reaching or carrying objects.

A common injury among boomers, a full tear may require surgery. Typically, the repair is made with an arthroscopic procedure.

Swenson recommends these exercises to strengthen the shoulder and avoid rotator cuff damage:

•Active Resisted Internal Rotation — stand square and grasp tubing (attached to door handle, e.g.), keep elbow at side and rotate arm inward across the body. Keep forearm parallel to the floor; repeat 30 times in three sessions a day.

•Active Resisted External Rotation — using tubing, keep elbow in at side and rotate arm outward to midline only. Keep forearm parallel to the floor; repeat 30 times in three sessions a day.